Inspection·August 16, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few remain free from signs and symptoms of hypertension. Interventions: Give anti-hypertensive and medications as ordered. Monitor for side effects such as orthostatic hypotension (A form of low blood pressure that happens when standing up from sitting or lying down) and increased heart rate (Tachycardia) and effectiveness. * Focus: The resident uses insulin. Goal: The resident will be free from any signs or symptoms of hyperglycemia (high blood glucose (blood sugar) or hypoglycemia (A condition where the blood sugar (glucose) levels drop below normal) through the review date. Interventions: Administer insulin ordered by physician. Monitor/document for side effect and effectiveness. Blood glucose monitoring per physician orders. Monitor/document/report PRN any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing ( A deep rapid, and labored breathing pattern often associated with metabolic acidosis, a condition where the body has too much acid), acetone breath (smells fruity), stupor coma(distinct states of impaired consciousness). Monitor/document/report PRN any signs or symptoms of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), Pallor (An abnormal or unusual paleness of the skin or mucous membranes, indicating a lack of color that is different from a person's normal complexion), Nervousness, Confusion, slurred speech, lack of coordination, staggering gait. Rotate site of insulin injections and document site of administration. Monitor for alteration in skin integrity. Record Review of physician orders based on Resident #1's MAR revealed Resident #1 had orders for: MetFORMIN HCl Tablet 1000 MG-(Give 1 tablet by mouth two times a day for diabetes with a start date of 06/02/25). Metoprolol Tartrate Oral Tablet 50 MG-Give 1 tablet by mouth two times a day for hypertension hold for SBP less than 110 and HR less than 55 with a start date of 06/03/25). AmLODIPine Besylate Tablet 10 MG-Give 1 tablet by mouth one time a day for hypertension hold for less than 110 or HR less than 55 with a start date of 06/04/25). HydrALAZINE HCl Tablet 25 MG-Give one tablet by mouth three times a day for hypertension hold for SBP less than 110 or HR less than 55 with a start date of 06/03/25). Record review of Resident #1's MAR for August 2025 revealed: On 08/09/25 Resident #1 received MetFORMIN HCl 1000 MG AT 9:00 a.m. On 08/09/25 Resident #1 received Metoprolol Tartrate Oral Tablet 50 MG at 9:00 a.m. On 08/09/25 Resident #1 received AmLODIPine Besylate Tablet 10 MG at 9:00 a.m. The residents blood pressure was documented as 144/78 and pulse was 76. On 08/09/25 Resident #1 received HydrALAZINE HCl Tablet 25 MG at 9:00 a.m. Record review of Resident #1's progress notes for August 2025 revealed: * On 08/09/25 at 11:30 AM, RN-A documented, Resident found lying in bed, family at bedside. Resident breathing without difficulty, no difficulty in swallowing, moving right arm, pupils respond to light, no verbal response, responds to pain, vital signs 203/98-78-20 (blood pressure) blood sugar 178, family insists we send to ER, MD notified and received order to send to hospital for evaluation. Record review of Resident #1's electronic health record revealed: On 08/09/25 at 11:30 a.m., Resident #1's blood sugar at 176, the residents blood sugar was not taken again. On 08/09/25 at 11:30 a.m., Resident #1's blood pressure was 203/98. The residents blood pressure was 144/78 at 12:47 p.m. and 144/78 at 12:54 p.m. Record review of the hospital's history of present illness for Resident #1 dated 08/09/25, the resident's blood glucose was 44 upon arrival to thehospital. The resident was admitted to the hospital for hypoglycemia. In an interview with Resident #1 on 08/14/25 at 10:57 a.m., she stated everything was going well. She stated the staff checked on her regularly. She stated she went to the hospital recently. She stated she did not know what happened. She stated she did not know what happened but reported that her daughter was with her. She stated she was feeling fine and stated the staff had been checking on her regularly. She stated she liked living at the facility and stated the staff are nice to her. In an interview with RN-A on 08/14/25 at 11:14 a.m., she stated she checked on the resident at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5:30 a.m. on 08/09/25 and Resident #1 was doing fine. She stated at approximately 11:30 a.m. on 08/09/25, a family member of the resident informed her that she was concerned about the resident. She stated she took the resident's blood pressure, and it was 203/98 and the resident's blood sugar was 178. She stated she contacted the on-call physician, and she was informed to send the resident to the hospital. She stated about 45 minutes later she checked the resident's blood pressure again and it was 180/78. She stated the resident was sent out via ambulance transportation. She stated she did not call 911 because the resident was breathing. She stated the resident was responding to touch, swallowing and moving her arms, but was not talking. She stated the resident left to go to the hospital before 1:00 p.m. In an interview with CNA B on 08/14/25 at 11:53 a.m., she stated Resident #1ad a change in condition on 08/09/25. She stated she did not know the exact time of the change in condition, but she remember that it occurred after breakfast. She stated the resident was not really talking and her normal baseline was usually alert and oriented. She stated the resident was sent out to the hospital, but she could not remember what time she was sent out. Interview with the DON on 08/14/25 at 12:24 p.m., he stated Resident #1 was sent out the hospital due to an elevated blood pressure. He stated he was not working the day the resident was sent out. He stated usually if a resident was alert and moving, the resident was sent out via transportation but if something else was going on with the resident they would be sent out via 911. In an interview with on-call Physician on 08/14/25 at 1:06 p.m., he stated RN-A informed him that Resident #1 had a change in condition, reporting a blood pressure of 203/98. He stated he told RN-A to send the resident to the hospital. He stated it was the facility's decision on which form of hospital transportation was used, but he would assume they would use the fastest method. He stated he assumed that 911 was called and was not aware that the ambulance transportation was called. He stated the risk of a resident not going out the hospital during a change in condition would depend on the resident and the situation In an interview with the Administrator on 08/14/25 at 1:51 p.m., he stated he was not employed at the facility when the resident was sent out but reported he was able to obtain information regarding the call outs and pick up from the transportation center. He stated RN-A contacted the ambulance transportation company at 11:22 a.m. and they arrived to pick the resident up at 1:13 p.m. A policy on change in condition was requested, and he stated there was no policy related to change to change only notification of changes. In an interview with Family Member #1 on 08/14/25 at 3:04 p.m., she stated she was with Resident #1 the day that she was sent out to the hospital. She stated she entered the resident's room at approximately 11:00 a.m. She stated the resident appeared to be in a deep sleep. She stated the resident was lying in bed with her eyes closed and it sounded as if she was snoring. She stated she called the resident's name several times, but she did not respond. She stated she began to shake the resident to get her to arise and she did not move. She stated she notified the nurse. She stated RN-A came into the room and attempted to wake the resident. She stated the resident did not move. She stated the resident's blood sugar was taken, and it was 86. She stated RN-A gave the resident a glucose stick and rubbed her throat to help her swallow but she would not swallow. She stated RN-A stated that she would contact the physician and asked if she wanted 911 to be called and she responded yes. She stated RN-A then stated that it would take an hour for the ambulance to arrive. She stated RN-A never returned to check on the resident. She stated 911 never arrived but reported an ambulance transportation company came instead. She stated the ambulance transportation company arrived around 1:30 p.m. Record review of the facility's Notification of Changes revised 12/08/24 revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 2. Significant change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status: This may include: a. Life threatening conditions, or b. Clinical complications This was determined to be an Immediate Jeopardy (IJ) on 08/14/2025 at 5:35 p.m. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were notified. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were provided with the IJ template on 08/14/2025 at 5:35 p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 08/15/25 at 1:54 p.m.: The facility failed to transfer [Resident #1], who had a change in condition at 11:30am in a timely manner. The facility failed to call 911 emergency services to immediately transport [Resident #1] to a higher-level of care for evaluation and treatment 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion/ Date: 8/14/25) [Resident #1] returned to facility on 8/12/25 with no ill effects related to alleged deficiency. DON/Regional /Nurse Consultant reviewed 24-hour report for the last 7 days to ensure all changes of conditions including transfers to acute care were addressed in a timely manner. An audit was conducted on all transfers from the last 7 days to acute care to ensure there was no delay in services. Attending Physician and Medical Director were notified of IJ on 8/14/2025 at 08:40pm. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/14/25) Facility policy and procedures related to change of condition were reviewed by Director of Nursing, Administrator, Regional Nurse Consultant and Senior Administrator on 8/14/2025, no revisions deemed necessary at this time. DON/Corporate Nurse/Consultant Nurse provided education to nurse involved in alleged incident with 1:1 education related to notifications of change of condition and monitoring of resident while resident remains in facility until transfer occurs or change of condition resolves. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). DON/Corporate Nurse/Consultant Nurse provided education to all staff in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and to report to licensed nurse the findings for immediate assessment. Education included definitions of what a change of condition is, circumstances where the licensed nurse or Director of Nursing must be notified, and when to notify responsible parties if appropriate. DON/Corporate Nurse/Consultant Nurse provided education to all licensed nurses in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and seeking immediate medical care as to not delay services. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). The Director of Nursing or designee will continue to monitor/audit Changes of Condition and Hospital Transfers by reviewing the 24-hour (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. * Monitoring of the plan of removal included the following: Record review of an Audit/Monitoring dated 08/11/25-08/14/25 revealed residents were reviewed for change in condition, actions taken to address change in condition. The document reflected if the resident were sent out via 911 or non-emergent transportation, was there any delays, comments/corrective action. There were no identified concerns in the audit. Record review of the Summary Report of Education dated 08/14/25 revealed all facility staff were educated on Notifications of Change in Condition by the DON and Senior Administrator. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of the Summary Report of Education dated 08/14/25 revealed all licensed staff were educated on Changes of condition and seeking immediate medical care as to not delay services by calling 911 if needed for transportation as appropriate for the identified change in condition by the DON. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of Summary Report of Education dated 08/15/25 revealed licensed staff were educated on Monitoring and assessment to be done when a resident who is diabetic has a change in condition by the DON. The document revealed in part, Hypoglycemia Management-It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode (Definition, Policy explanation, Compliance guidelines, asymptomatic and responsive residents, symptomatic (lethargic, drowsy) but responsive (conscious) residents). Record review of In-service Summary/Report of Education of 1:1 with the DON and RN A dated 08/14/25 revealed RN A was educated on change of condition-monitor resident vital signs, document-all-clinical changes, monitor resident until 911 arrives, document time start and finish, call NP/MD, DON, and RP. Interviews were conducted with staff on 08/14/25 between 5:35 a.m. until 12:00 p.m. including RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q were able to explain the importance of monitoring the residents that had a change in condition, calling 911 when the residents have a change in condition (high/low blood sugar and high/low blood pressures), taking residents vitals until 911 arrived, staying with the resident until 911 arrived, and documenting all changes. The Administrator was informed the Immediate Jeopardy was removed on 08/16/2025 at 12:02 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455815 If continuation sheet Page 5 of 5